Source · Prevention of Future Deaths

Matilda Davis

Ref: 2026-0198 Date: 7 Apr 2026 Coroner: Deborah Sewell Area: Warwickshire Responses identified: 1 / 2 View PDF

Suicide prevention training is not mandatory for frontline practitioners within Warwickshire Children’s Services, potentially leading to variability in practice when responding to indications of self-harm or suicidal thoughts.

Date 7 Apr 2026
56-day deadline 2 Jun 2026
Responses identified 1 of 2
Suicide (from 2015)

Coroner's concerns

AI summary
Suicide prevention training is not mandatory for frontline practitioners within Warwickshire Children’s Services, potentially leading to variability in practice when responding to indications of self-harm or suicidal thoughts.
View full coroner's concerns
Evidence heard during the inquest confirmed that suicide prevention training is not mandatory for frontline practitioners and staff within Warwickshire Children’s Services. The social worker and support worker who visited Matilda had not received suicide prevention training, although such training was available within the organisation. In the absence of mandatory suicide prevention training, Matilda was not asked directly about suicidal ideation during the visit, where reference was made to suicidal thoughts within the referral context.  It was also noted that she was not signposted to crisis support services at that time. The non-mandatory nature of suicide prevention training may give rise to variability in practice when practitioners are required to explore, record, or respond to indications of possible self harm or suicidal thoughts.

Responses

1 respondent
Warwickshire County Council Local Authority
7 Apr 2026 PDF
Action Planned

Warwickshire County Council has reviewed its suicide prevention training and will introduce a mandatory three-tier training model for all frontline Children’s Services staff. This will include basic awareness, advanced intervention skills, and organisational response, with compliance monitored through HR systems. (AI summary)

View full response
Dear Life). A refreshed and regularly reviewed suicide prevention intranet page will act as the central resource hub, building on the existing WCC Suicide Prevention page and ensuring consistent access to guidance and training materials, as well as signposting resources. This e-learning offer will be available to all staff across WCC as a universal awareness resource; however, at this stage, mandating completion will be prioritised within Children & Families, subject to further corporate agreement. Delivered through: o Short e-learning or facilitated sessions o Supported by a single, accessible resource hub Tier 1 Delivery Model and timescale Delivered to all Children and Families frontline staff within 3 months. Tier 2 – Practitioner response (mandatory) This tier is designed for staff working directly with individuals at risk, including social workers, family practitioners, and personal advisors. The focus is on developing applied skills and confidence in:  Asking direct questions about suicidal thoughts  Understanding risk and protective factors in context  Working with families and multi-agency partners  Safety planning within professional boundaries Training will be structured, interactive and practice-based, with all participants taking part in facilitated sessions that include applied exercises such as role-play, scenario-based discussions, and skills rehearsal. Content will be informed by learning from the Handling Suicidal Conversations pilot programme and delivered ensuring consistency, quality assurance, and alignment with recognised suicide prevention training standards. Tier 2 Delivery Model and Timescale Delivery of Tier 2 training will follow a phased three-year implementation model, reflecting both financial considerations and workforce capacity.  Approximately 200 staff will be trained per year  Total of 600 staff trained over three years  Total cost estimates are significant Delivery will:

Miscellaneous/DAVIS (Matilda)/MC66258/Ann Hume/11,492,750.00  Move beyond awareness to interactive, scenario-based learning  Provide space for reflection and discussion  Support practitioners to manage uncertainty and professional anxiety Initial rollout will prioritise practitioners working directly with children and families, alongside their line managers, to ensure both frontline capability and effective supervisory oversight. Based on this approach:  All identified Children & Families staff will complete Tier 2 training within three years of commencement with the first cohort of staff starting their training in the Autumn of
2026. Training will not be a one-off intervention:  A refresh requirement will apply every three years  Earlier refresh may be required following role change, incident learning, or updated practice guidance Following initial rollout, delivery will transition into a business-as-usual model permitting funding, including:  Ongoing training for new starters  Scheduled refresher cycles  Gradual expansion to wider workforce groups subject to funding agreement. Due to the scale of investment, commissioning of Tier 2 training will be subject to a formal procurement tender process in line with organisational requirements. As such options will be finalised following a competitive tendering exercise. In person and online options will be considered with the preference to be for frontline staff who hold cases to have in person training. Commencing Autumn 2026. Tier 3 – Leadership and post-incident support (Mandatory) This tier focuses on strengthening organisational response and workforce wellbeing. It includes:  Supporting managers to provide reflective supervision  Managing complex risk and professional anxiety  Establishing psychologically safe team environments It will also introduce a clear and consistent post-incident pathway, including:  Immediate response following a death or serious attempt  Structured team debriefs  Ongoing emotional and psychological support Tier 3 Delivery model and Timescales Existing support services can be used to deliver this support. Some updates to intranet pages will be needed and this can be completed by July 2026.
3. Action Plan Summary Training uptake and compliance will be monitored through corporate HR booking systems, enabling reporting at team level (e.g. percentage completion rates). This will support oversight through existing performance management arrangements, including quarterly reporting from the Practice & Learning Hub Service Manager to the Children & Families Performance Board. Individual compliance will also be monitored using the established Workforce Health and Safety tracker. Suicide awareness training can be incorporated into this tracker to enable

Miscellaneous/DAVIS (Matilda)/MC66258/Ann Hume/11,492,750.00 monitoring of individual attendance, in line with existing processes used by Service Managers. The proposal supports improved outcomes for high-risk groups, including care leavers, and promotes more consistent and equitable responses to suicide risk. Training will emphasise inclusive, trauma-informed practice and support staff to engage sensitively with diverse communities.
4. Conclusion Warwickshire County Council believes these actions directly address the matters of concern raised by the coroner. Signed , Executive Director, Children & Young People (Director of Children’s Services) Warwickshire County Council Date: 29/5/2026

Report sections

Investigation and inquest
I conducted an inquest into the death of Matilda Rose Davis otherwise known as Matilda Rose Southhall. The inquest concluded on the 20th March 2026. Matilda died on the 3rd October 2025 at her home address of  [REDACTED]. 

The medical cause of death was confirmed as

1a) Suspension by a ligature around the neck.

I recorded a short-form conclusion of Suicide.
Circumstances of the death
On 3rd October 2025, Matilda was found deceased at her home in Stratford-upon-Avon. Earlier that day, Warwickshire Children’s Social Care had conducted an urgent safeguarding visit following concerns raised by her estranged husband regarding her mental health and the welfare of their two children. During the visit, Matilda reported experiencing emotional and psychological strain arising from relationship conflict, financial pressures, and the ongoing divorce proceedings. She also described recent episodes of head-banging behaviour and confirmed aspects of her medical history, including discontinued antidepressant medication and a current prescription for diazepam. She stated that she intended to arrange a further GP appointment. Before concluding the visit, the attending social worker and the support worker noted that Matilda’s demeanour was calm and that she expressed no suicidal ideation. Shortly after their departure, Matilda was found hanging by a ligature attached [REDACTED]. There was no evidence of forced entry. The emergency services attended, but Matilda was pronounced deceased at 16:26 hours on 3rd October 2025.

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Report details

Reference
2026-0198
Date of report
7 April 2026
Coroner
Deborah Sewell
Coroner area
Warwickshire

Responses identified

Responses identified 1 of 2
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 Jun 2026.

Sent to

Warwickshire County Council – Children and Young People
Warwickshire County Council – Children with Disabilities team

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